title: An ethnographic exploration of influences on prescribing in general practice: why is there variation in prescribing practices?
abstract: BACKGROUND
  Prescribing is a core activity for general practitioners, yet significant variation in the quality of prescribing has been reported. This suggests there may be room for improvement in the application of the current best research evidence. There has been substantial investment in technologies and interventions to address this issue, but effect sizes so far have been small to moderate. This suggests that prescribing is a decision-making process that is not sufficiently understood. By understanding more about prescribing processes and the implementation of research evidence, variation may more easily be understood and more effective interventions proposed.
  
  
  METHODS
  An ethnographic study in three Scottish general practices with diverse organizational characteristics. Practices were ranked by their performance against Audit Scotland prescribing quality indicators, incorporating established best research evidence. Two practices of high prescribing quality and one practice of low prescribing quality were recruited. Participant observation, formal and informal interviews, and a review of practice documentation were employed.
  
  
  RESULTS
  Practices ranked as high prescribing quality consistently made and applied macro and micro prescribing decisions, whereas the low-ranking practice only made micro prescribing decisions. Macro prescribing decisions were collective, policy decisions made considering research evidence in light of the average patient, one disease, condition, or drug. Micro prescribing decisions were made in consultation with the patient considering their views, preferences, circumstances and other conditions (if necessary).Although micro prescribing can operate independently, the implementation of evidence-based, quality prescribing was attributable to an interdependent relationship. Macro prescribing policy enabled prescribing decisions to be based on scientific evidence and applied consistently where possible. Ultimately, this influenced prescribing decisions that occur at the micro level in consultation with patients.
  
  
  CONCLUSIONS
  General practitioners in the higher prescribing quality practices made two different 'types' of prescribing decision; macro and micro. Macro prescribing informs micro prescribing and without a macro basis to draw upon the low-ranked practice had no effective mechanism to engage with, reflect on and implement relevant evidence. Practices that recognize these two levels of decision making about prescribing are more likely to be able to implement higher quality evidence.
authors.affiliation: Population Health Sciences, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, Scotland DD2 4BF, UK. a.m.grant@dundee.ac.uk
authors.forename: Aileen
authors.initials: A
authors.lastname: Grant
authors.forename: Frank
authors.initials: F
authors.lastname: Sullivan
authors.forename: Jon
authors.initials: J
authors.lastname: Dowell
mesh_terms: D000884:Anthropology, Cultural; D002983:Clinical Competence / Q000592:standards; D003657:Decision Making; D004345:Drug Industry; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D005569:Formularies as Topic; D058006:General Practice / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007400:Interprofessional Relations; D008962:Models, Theoretical; D010594:Pharmacies; D010818:Practice Patterns, Physicians' / Q000592:standards* / Q000706:statistics & numerical data; D011787:Quality of Health Care; D012606:Scotland